3. Surgical Aspect Of Large Bowel. Pptx.pdf

SURGICAL ASPECT OF LARGE BOWEL DISEASE Ign.Riwanto MD PhD Prof. of Digestive Surgery

SURFACE ANATOMY 1.  LEFT LUMBAR: Coecum, ascending colon, hepatic flexure 2.  UMBILICAL Transverse colon 3. RIGHT LUMBAR: Splenic flexure, descending colon, sigmoid 4. LEFT INGUINAL: Sigmoid 5. HYPOGASTRIC: Sigmoid & Rectum

ORGAN RELATED & POSITION OF LARGE BOWEL

- GASTRO-COLIC

LIGAMENT - OMENTUM MAYUS - Coecum: Intraperitoneal - Ascending colon: retroperitoneal - Transverse colon: intraperitoneal - Descending colon: retroperitoneal - Sigmoid: intraperitoneal - Rectum: retroperitoneal

DETAIL ANATOMY OF COLON § 3-5 FEET IN LENGTH § ILEOCOECAL JUNCTION WITH ILEOCOECAL VALVE § APPENDIX § COECUM IS WIDES, PROGRESSIVELY NARROW DISTALLY à ANAL CANAL § 3 TAENIA (CONDENSED OF LONGITUDINAL MUSCLE LAYER,CONVERGE AT THE BASED OF APPENDIX AND SPREAD AT RECTUM) § HAUSTRA § INCISURA § APPENDICES EPIPLOICAE

RECTUM §  RETROPERITONEAL §  12-15 CM IN LENGTH § ANORECTAL JUNCTION : ANGLE DUE TO PUBO-RECTAL MUSCLE § WALDEYER’S FASCIA: RECTOSACRAL FASCIA § DENONVILLERS’ FASCIA: ANTERIOR LOWER THIRD OF RECTUM , RELATED TO THE PROSTAT (MALE) AND VAGINA (FEMALE)

RECTUM & ANAL CANAL §  3 RECTAL VALVE (INFERIOR, MIDLE & SUPERIOR) §  ANATOMICAL ANAL CANAL: ANAL CANAL SKIN §  SURGICAL ANAL CANAL: ANAL CANAL SKIN & MUCOSA §  INTERNAL ANAL SPHINCTER (SMOOTH MUSCLE FIBER CONTINUATION OF CIRCULAR MUSCLE OF THE RECTUM, START FROM ANORECTAL JUNCTION), 80% RESTING ANAL CLOSING. §  3 EXTERNAL ANAL SPHINCTER (STRIATED MUSCLE FIBER), 100% SQUEEZING ANAL CLOSING §  INTERSPNCHTERIC GROVE §  ANAL PAPILA & COLLUMNS OF MORGAGNI §  ANAL CANAL CRYPT §  ANAL CANAL GLAND §  NO HAIR IN ANAL CANAL SKIN §  INTERNAL & EXTERNAL HEMORRHOID PLEXUS

ARTERY SUPERIOR MESENTERIC ARTERY: Coecum, Ascending colon & 2/3 transverse colon (midgut) INFERIOR MESENTERIC ARTERY: 1/3 distal transverse colon, sigmoid & rectum (hind gut) MIDLE & INFERIOR RECTAL ARTERY (branches from INTERNAL ILEAC ARTERY): rectum & anus

VENOUS SYSTEM §  PORTAL SYSTEM §  SUPERIOR MESENTERIC VEIN & SPLENIC VEIN form PORTAL VEIN, and INFERIOR MESENTERIC VEIN drain to SPLENIC VEIN §  MIDLE & INFERIOR RECTAL VEIN drain to INTERNAL ILIAC VEIN §  HEMORHOIDAL COMPLEX: collateral PORTAL- SYSTEMIC SYSTEM

LYMPH ATIC SYSTEM 3 TYPES:

Ø  Epicolic Ø  Paracolic Ø  Intermediate (name according artery they follow Ø Main/ principal : around SMA & IMA à para-aortal à cysterna chili à thoracic duct à left sub-clavian vein (Vircow’s node) Distal rectum & anus : drain to inguinal lymph node

INNERVATION § AUTONOMIC NERVOUS SYSTEM § SYMPATHETIC (Inhibit peristaltic): - T7-T12 : RIGHT COLON & - L1-L3 : LEFT COLON § PARA-SYMPATHETIC (stimulate peristaltic): - VAGUS NERVE: RIGHT COLON - SACRAL (S2-4): LEFT COLON INTRINSIC INNERVATION: MEISSNER;S PLEXUS: submucosal AURBACH PLEXUS: circular muscle layer

PHYSIOLOGY — Absorbtion of water & electrolyte :

especially right colon — Storage of feces — Fecal movement & delivery

COLON MOTILITY —  RETROGRADE MOVEMENT: Transverse

colonà coecum to facilitate the absorption water & electrolyte —  SEGMENTAL CONTRACTION: Simultaneous segmental contraction of circular and longitudinal muscle —  MASS MOVEMENT: Contraction long segment, 30 seconds duration à antegrade propulsion feces at the rate 0.5-1 cm/sec, 3-4 times each day after waking up & after eating.

DEFECATION —  Mass movement à feces move to rectum —  Rectal distentionà involuntary relaxation of

internal sphincter —  Voluntary relaxation external sphincter à pushes feces down to anal canal —  Voluntary increase intra-abdominal pressure à propeling feces out of the anus

DISORDER MOTILITY OF COLON & RECTUM

DISORDER MOTILITY — Iritable Bowel Syndrome (IBS) — Constipation — Diarrhea — Fecal incontinence

IRRITABLE BOWEL SYNDROME —  Abnormal state of intestinal motility modified by

psychosocial factors, no anatomic cause —  Male: female= 1:2 —  Incidence: Up to 17% (US) —  Episode of altered bowel function (constipation, diarrhea or both) intermittently over prolonged period with or without pain —  Treatment: reassurance, education, medical treatment for anxiety/ depression

CONSTIPATION —  < 3 stools/ week while consuming high fiber —  Acute: persisten for < 3 months —  Chronic: persistent > 3 months —  Cause: Less fiber, less fluid, lack physical activity, medication

(opiate), IBS, DM, hypothyroidism, Hirsprung disease, depression, Parkinson's disease, multiple sclerosis, rectocele, others. —  Treatment: Stool softener, increasing fiber & fluid —  Failure: colonic transit time, defecography , manometri —  Fecal impaction: manual disimpaction —  Surgery for rectocele, Hirsprung disease, prolong transit time

SCINTIGRAPHY

Normal: within 48 hours of ingestion much of the radioisotope has been passed from bowel

Severe constipation due to prolonged transit time, over the 4 days radioisotope does not progress beyond the thansverse colon

RADIOLOGIC MARKER —  Radio-opaque marker tablet —  20 tablet, followed by serial daily

abdominal X-ray —  Normal: Ø  80% had passed by the end of 5th days Ø  TT through right colon 6.9-13.0 hours Ø  TT through left colon 9.1-15 hours Ø  TT through rectosigmoid 11-18.4 hours —  More than 40% marker left in the colon after 5 days considered pathology.

Colonic inertia

Hindgut inertia

Outlet obstruc tion

§  Rectocele: Anterior outpocketing of the rectal wall with incomplete evacuation §  High incidence of ventral outpocketing §  Vaginal bulging during straining & digitation for success defecation §  Surgery: anterior levator mplasty

HIRSPRUNG’S DISEASE §  AGANGLIONIC IN THE NARROWING PART §  DILATED PART: ACCUMULATION OF FECES & COMPENSATION §  SURGERY § 

DIARRHEA —  Passage of >3 loose stools/day —  Surgery related: short bowel syndrome (less than 70 cm

of small intestine left) —  Conservative: imodium, elemental diet, parentaral nutrition —  The rest of the small intestine will hypertrophy

FECAL INCONTINENCE —  True: Complete loss of solid stools —  Minor: Flatus or soilage undergarment from seepage or

urgency —  Decreasing resting tone and squeeze pressure —  Etiology: Sphincter injury, scleroderma, fecal impaction, pudendal nerve injury. —  Diagnosis: anal manometry, endoanal ultrasonography, electtro-myography, Pudendal nerve motor latency. —  Surgery: sphincter repair for sphincter injury.

COLITIS

COLITIS —  Amoebic colitis: due to E histolytica, diagnosis based on fecal —  — 

—  — 

— 

microscopy or serum amoeba. Pseudomembranous: (overgrowth Clostridium difficile after using clindamycin, amphicillin or cephalosposin) Actinomycosis: Rare infection of cecal region caused by A. israelii, classically after appendectomy, may produce abscess & fistulation that need surgical drainage & antibiotics (tetracycline or penicillin) Netropenic: colonic mucosal ulceration after chemotherapy in cancer patients, may perforation à surgery. Radiation induced: after radio-therapy more than 5.000 cGy, early presentation: bleeding & diarrhea, late presentation: stricture & fistula à need surgery Ischemic: due to decrease perfusion or tromboembolism, if conservatif treatment failà resection with colostomy

INFLAMMATORY BOWEL DISEASE (IBD) —  CROHN’S DISEASE —  ULCERATIVE COLITIS Ø  BOTH AUTO IMMUNE DISEASE

CROHN’S DISEASE

ULCERAITIVE COLITIS

ULCERATIVE COLITIS vs CROHN’S DISEASE ULCERATIVE

CROHN

- Inflamation of the mucosa only - Start in rectum

- Involve all bowel wall layers - - rectal sparing 50%

- Continous lessions - Rare -  Lead pipe colon

- Skip lesions - Aphthous ulcer -  Cable stone appearance

Complication

-  Perforation -  Stricture -  Megacolon

- Abscess -  Fistula - Obstruction - Perianal disease

Treatment

Mild to moderate : 5-ASA, corticosteroid p.o/ per rectum Severe: IV steroid Surgery: Failure medical theraphy, complication, dysplasia and neoplasia à colon resection or diverting colostomy

Pathology Diagnosis - Colonoscopy - Colonography

DIVERTICULAR DISEASE

DIVERTICULAR DISEASE —  Herniation of mucosa & sub-mucosa through sites where

arterioles penetrate à outpouching (diverticula), in the mesenterial side —  Diverticulosis = multiple diverticula —  Sigmoid most common —  Old age & low fiber intake —  Asymptomatic (80%), massive lower GI bleeding, pain (diverticulitis), peri colic abscess formation, perforationà peritonitis —  Dx: colonography, colonoscopy —  Tx: high fiber & stool softener, antibiotics in diverticulitis, surgery for failure of stop bleeding & complication

DIVERTICULOSIS vs ANGIODYSPLASIA as the cause of Lower GI Bleeding Diverticulosis

Angiodysplasia

Incidence

50% > 60 Yeras

25 % > 60 Years Adult Men > adult women

Character

Painless 75% bleed from right colon

Coecum and ascending colon

Quantity and rate

Massive and rapid

Slow

Sign & Sympt.

Melena and /or hematoschezia often with symptom of orthostasis

Dx

-  NGT to rule out upper GI bleeding - Identify bleed (colonoscopy, Tc sulfur colloid, Angiography)

Tx

1.  Rescucitation 2.  Octreotide, embolization, epinephrine, vasodestruction with alcohol, coagulation/ coutery 3.  Massive identified site à segmental colectomy 4.  Massive unidentified site à total colectomy

COLONIC OBSTRUCTION

COLONIC OBSTRUCTION Cause: —  Cancer, —  Vulvulus coecum —  Volvulus Sigmoid —  Pseudo-obstruction syndrome (Ogilvie Syndrome)

SIGN & SYMPTOM —  Abdominal distention —  Cramping abdominal pain —  Nausea and vomiting —  Obstipation —  High pits Bowel Sound

DIAGNOSTIC —  Abdominal X ray: distended proximal colon with air-fluid

level and no air distally —  Coffe bean (kidney) appearance: Coecal , Sigmoid Volvulus —  Colonography: to ruled out pseudo-obstruction —  Colonoscopy: contra-indicated, but can be used to treat pseudo-obstruction.

ILEUS OBSTRUKSI RENDAH (COLON) —  Kolik abdomen graduel —  Gangguan bowel habit sebelumnya pada —  —  —  —  —  — 

— 

— 

keganasan kolon-rectum Kembung seluruh perut dgn gambaran & gerakan usus Tidak bisa berak dan kentut Mual, muntah bila sudah lanjut (fecal) Perut kembung peristaltik meningkat bisa ada suara metalik RT kollaps (atau teraba tumor rektum) BNO: dilatasi kolon (haustra & incisura, air fluid level yang panjang di kolon ascenden, bila val ileosekalis inkompetent usus halus ikut melebar) Colonografi/ CT scan dengan kontras untuk menyingkirkan DD pseudoobstruksi Terapi: pembedahan, kemungkinan kolostomi perlu diinformasikan

CT scan abdomen

Obstruksi sigmoid oleh karena karsinoma (ada penyangatan pada fase kontras)

Volvulus Sigmoid —  Bentuk kronik dan akut —  Nyeri perut mendadak dan

menetap karena iskemia (akut) —  Bulging dan gambaran usus —  Nyeri tekan —  Defance muskuler bila telah nekrosis/ perforasi —  Foto: Cofee bean appearance —  Coba konservatif dengan rectoscopi decompresi dilanjutkan pembedahan elektif untuk tipe kronik —  Gagal/ tanda nekrosis à operasi segera —  Tipe akut: laparatomi emergency

CT Scan

PSEUDO-OBSTRUKSI DI FLEKSURA LIENALIS COLON

ALGORITM MANAGEMENT OF COLON OBSTRUCTION

TREATMENT —  NGT —  Fluid & electrolyte correction —  Pseudo obstruction:

- Neostigmin - Decompressed by colonoscopy - Coecal diameter more than 11 cm or sign peritonitis à Operation: ccoecostomy —  Coecal volvulus: Right hemicolectomy —  Sigmoid volvulus: - Sigmoidoscopy to decompress followede by elective resection - Failure or sign of peritoneal iritation: emergency resection §  Cancer : resection or fecal diversion

HEMORRHOID

HEMORRHOID —  Prolapse of the sub-mucosal vein ( 11,3,& 7

o’clock) —  Internal: covered by mucosa —  External: covered by skin —  Risk factor: constipation, excessive diarrhea, pregnancy, increase pelvic pressure, portal hypertension.

DEGREE OF INTERNAL HEMORROID —  1st stage: congestive non

prolapsed hemorrhoids —  2nd stage: prolapsing during defecation, reducing spontaneously at the end of defecation, —  3rd stage: prolapsing during defecation and requiring manual reduction —  4th stage: permanently prolapsed which cannot be reduced manually

Abramowitz et al. Gastroenterologie June-July 2001.

RELATIONSHIP BETWEEN PATHOGENESIS AND MODE OF TREATMENT —  GENERAL: Ovoid/ minimizing the risk factors, anti-

inflammatory drugs, faeces softener

—  VASCULAR THEORY: Ø  - Phlebotrophic drugs (micronized diosmin) Ø  - Excision of hemorrhoidal tissue —  INCREASE LAXITY OF HEMORRHOIDAL SUPPORT

TISSUE: Ø  - Sclerotheraphy Ø  - Rubber band ligation Ø  - Longo hemorrhoidectomy Ø  - Hemorrhoid artery ligation and Recto-anal repair Ø  - Phlebotrophic drugs

GRADE OF INTERNAL HEMORRHOID & ITS TREATMENT —  Grade 1: Medical treatment —  Grade 2: Medical and Ruber Band ligation or

Sclerotherapy —  Grade 3: Medical and surgery —  Grade 4. Medical and surgery

Excision of Hemorrhoidal tissue —  OPEN METHOD Ø Morgan milligan

—  CLOSED METHOD Ø Fergusson Ø Park Ø White head

Morgan Milligan —  Internal Hemorrhoid grade

II-IV —  Removing anal cushion including the skin —  Left the wound open —  Severe post operative pain

Fergusson —  Internal Hemorrhoid grade

II-IV —  Removing anal cushion including the skin —  Suturing the wound —  Severe post operative pain

Park —  Internal Hemorrhoid grade

II-IV —  Submucous removing Hemorrhoidal plexus —  Suturing the wound —  Post operative pain

before

Longo’s technique is based on the theory of increase laxity of hemorrhoidal support tissue after

HEMORRHOID ARTERY LIGATION (HAL) AND RECTO-ANAL REPAIR —  HAL: first reported by Morinaga (Japan) 1995 —  Because the arteries carrying the blood inflow are ligated,

internal pressure of the plexus hemorrhoidalis is decreased, shrink and become smaller. —  HAL: high prolapse recurrence in grade IV à 2005 RAR (Recto-Anal Repair) —  RAR = Proctoplasty/ mucopexy is lifting the hemorrhoid back to where the belong. The American Journal of Surgery, 2006

INSTRUMENT FOR HAL-RAR —  Single system that has two

procedure options, (Doppler Guided) Hemorrhoidal Artery Ligation and Recto Anal Repair (Proctoplasty).

Step for Hemorrhoid Artery Ligation (HAL)

Step for Recto-Anal Repair (RAR)

Prolaps Rektum

Epidemiologi —  terjadi pada umur yang ekstrem, anak sampai umur 3 tahun

dan pada orang tua. —  Lebih sering pada wanita tua dengan perbandingan 10-15:1 —  Pada anak laki & wanita sebanding

Anamnesa Keluhan utama: - penonjolan rectum keluar anus pada prolaps lengkap (3/4 kasus) - pada pre-prolaps (intususepsi rektal) ada rasa penuh dan terasa ada masa didalam rektum yang menutup anus Keluhan lain: - konstipasi - inkontinensia alvi - pengeluaran mukosa Etiologi: - kesulitan defekasi - nulipara - riwayat operasi sekitar anus: hemorroidektomi, fistulektomi, “abdomino anal pullthrough”

Pemeriksaan fisik Inspeksi

Palpasi

: - penonjolan konsentrik mukosa rektum berbeda dari hemmorroid prolaps dengan adanya lobulus dengan sulkus diantaranya, sementara dibedakan dari polips yang prolaps dengan adanya tangkai - terjadi strangulasi à kehitaman - kemungkinan bisa diidentifikasi polip diujung prolaps sebagai penyebab : - prolaps apakah bisa direposisi - tonus sfingter ani, pada keadaan istirahat (resting) dan kontraksi (squeezing), kebanyakan kasus sfingter lemah - pada pre-prolaps pada colok rektal, dengan dibantu mengejan, akan teraba masa seperti portio

PROLAPS RECTI

HEMORRHOID

Pemeriksaan penunjang Rektosigmoidoskopi - dilihat adanya polip atau karsinoma yang menjadi titik awal dari prolaps - dilihat derajat prolaps, hanya mukosa atau seluruh lapisan - dilihat apakah ada “solitary ulcer” , berupa ulkus dengan tepi hiperemik dikelilingi indurasi, akan tetapi bisa juga dalam bentuk indurasi mukosa bahkan lesi polipoid didinding depan rektum sekitar 6-8 cm dari anal verge. Colon foto atau colonoskopi - disarankan untuk orang tua sebelum merencanakan operasi Colon-transit time - dilakukan bilamana terdapat konstipasi, untuk memastikan apakah konstipasi tipe “prolong transit time” atau “outlet obstruction type”. Defecogram - dilakukan pada partial prolaps, mungkin akan bisa dilihat adanya intususepsi rectal, tumor (polip) rectum dan rectocele.

PROLAPS REKTI

Internal (Intususepsi rektal)

Eksternal (prolaps lengkap) gagal

Managemen medik

Toleransi operasi besar < baik

Necrose (-)

Toleransi operasi besar baik

Necrose (+)

Konstipasi (-)

Konstipasi (+), sigmoid redunden

* ** Thiersch

Delorme

Express

* Dipilih bila beserta konstipasi / sigmoid redundan

Altemier

Ripstein

** Dipilih bl bsm rectocele

Laparoskopi rektopeksi ventral

Sigmoidekt omi + Ripstein

ANAL FISURA

ANAL FISSURE —  Painful linear tear in anal canal skin (below dentate line) —  Induced by constipation, excessive diarrhea, anal sex. —  Painful defecation with bright red blood in the toilet tissue —  Increase resting sphincter tone —  Visible tear on examination —  Tx: —  medical: sitz bath, fiber diet, increase fluid intake, —  Internal lateral spinchterotomy in case of medical Tx fail

SPHICHTEROTOMI INTERNA SUBCUTAN LATERALIS

PERI-ANAL ABSCESS & FISTULA

PERI-ANAL ABSCESS & FISTULA —  Abscess caused by defect or obstruction of anal crypt

resulted in bacterial overgrowth in the anal glands —  Tx Surgical drainage —  May developed anal fistula (internal opening in the anal crypt, external opening peri-anal) —  Classification of fistula: —  Intersphincteric (70%), Transsphincteric (25%), Suprasphincteric (4%), Extrasphincteric (1%) —  Tx: Fistulotomy, Seton for Supra & extrasphincteric.

Para-anal abscess

PARA-ANAL FISTULA

Goodsall’s Rule —  Tract anterior (A) berupa

garis lurus, sedangkan tract posterior (P) berupa garis lengkung —  Secondary opening anterior yang berjarak > 3 cm dari anal margin, akan membentuk garis lengkung berhubungan dengan anal gland posterior

Klasifikasi fistula ani menurut Parks

COLORECTAL CANCER

Age Standardized Minimum Incidence Rate (ASR) 5 prominent cancer in Semarang (Tirtosugondo 1986)

1970-1974

1980-1981

Man Location

Woman ASR

Location

/100.000

Man ASR

Woman

Location

ASR /

Location

ASR /

/100.000

100.000

100.000

Liver

5,2

Cervic

19,8

Liver

9,5

Cervic

27,9

Skin

4,3

Breast

10,2

Lung

7,6

Breast

13,0

Lung

4,0

Ovarium

5,1

6,1

Skin

6,7

Naso pharynk Colorectal

3,6

Skin

4,9

Naso Pharynk Skin

6,1

Ovarium

3,9

2,5

Colorectal

2,2

Colorectal

3,2

Colorectal

3,4

Increase incidence of colorectal cancer in Semarang

FAKTOR YANG BERPERAN TERHADAP HARAPAN HIDUP PASIEN KANKER KOLON-REKTUM —  1. Stadium penyakit —  2. Derajat keganasan (histologik) —  3. Komplikasi (tersumbat, pecah) —  4. Dokter spesialis bedah (keputusan tindakan berdasarkan —  —  —  —  — 

stadium, pilihan pengobatan dan skill pembedahan) 5. Panas pasca-bedah 6. Tranfusi darah 7. Pengobatan tambahan 8. Petanda molekular (Mutasi K-ras respons chemoterapy jelek) 9. Lain-lain

PERKEMBANGAN ALAMIAH KANKER paparan Perubahan biologik

gejala waktu terdeteksi

sembuh/mati

A Skrining faktor risiko

B

C

Periode

Periode

subklinis Skining utk

klinis diagnosis

deteksi

dini

D

dini

A: Skrining, B: Deteksi dini C: Diag.nosis dini D, Management & prognosis

Periode A dan B utamanya untuk kelompok risiko tinggi Umur Penyakit terkait

Riwayat penyakit Riwayat keluarga

> 40 (>50) laki = wanita Ulcerative colitis Crohn disease Peutz-jegher Syndrome Kanker dan polip usus besar Kanker kandungan dan buah dada Juvenile polyp Familial adenomatosis polyps Familier polyposis syndrome Kanker dan polip usus besar

SURVEILANCE COLONOSCOPI: POLIPEKTOMI ATAU BIOPSI

FLEXIBLE SIGMOIDOSCOPY —  Kanker Rektum

& kolon kiri 70-80% kanker kolo-rektal —  Flexibel sigmoidoskopi

bisa mencapai fleksura lienalis, masih diperlukan kolon foto untuk melihat sisa kolon

Kolonoskopi: Diagnosis & Pengobatan

Colonoscopy and biopsy is the only way to make a definitive diagnosis of colorectal cancer. A barium enema can be used in cases where colonoscopy is difficult. (Adenis et al. Standards, options and recommendations: Carcinoma of the colon. Elec. J of Oncol 2001)

Periode C. Diagnosis awal setelah muncul gejala klinis Kolon kanan

Kolon kiri

Rektum

Nyeri perut samarsamar

“gas pain cramps”

Nyeri pada stadium lanjut

Diare coklat/ hitam

Darah segar pada kotoran

Darah segar pada kotoran

Anemi

Tinja kaliber kecil

Tidak puas setelah berak

Benjolan perut sisi kanan

Perubahan kebiasaan berak, butuh pencahar

Nyeri sewaktu berak dan berak sering

Tanda sumbatan

Morning diarea (lendir)

Pemeriksaan fisik —  Tanda obstruksi atau peritonitis —  Tumor masa intra abdomen (ukuran, lokasi, mobilitas,

konsistensi) —  Pembesaran hepar —  Sr Marie Nodule (nodule sekitar umbilicus): terdapat peritoneal seeding —  L.n. inguinal —  Rectal toucher

RECTAL TOUCHER —  Kanker dubur (rektum) >50% dari seluruh kanker usus besar) —  Colok dubur: 2/3 distal dari dubur —  Pasien diminta mengejan : tumor 1/3 proximal mobil dapat diraba —  Diskripsikan: jarak dari anal verge, besar, lokasi thd lingkaran

rektum, kerapuhan, mobilitas terhadap dinding rektum dan terhadap organ sekitar (mobile, tethered atau fixed) serta limfonodi di mesorektum.

PROKTOSIGMOIDOSKOPI —  Dilanjutkan foto kolon

dobel kontras untuk melihat sisa kolon (adanya synchronous tumor) —  Deskripsi tumor —  Jarak tumor dari anal verge —  Biopsi/ polipektomi

FOTO KONTRAS USUS BESAR —  Bukan tindakan pertama tetapi

disarankan sebagai kelanjutan proktosigmoidoskopi, fleksibel sigmoidoskopi atau kolonoskopi yang tidak bisa melihat sekum —  Foto kontras ganda pilihan terbaik —  Perkembangan baru: Virtual CTColonography à bisa melihat kondisi intralumen colon yang diisi kontras udara à mendeteksi polip/ tumor.

KANKER USUS BESAR, TUMBUH KEDALAM, ATAU MELINGKAR, PADA FOTO AKAN NAMPAK KONTRAS TISAK MENGISI PENUH ATAU MENYEMPIT

SIFAT-SIFAT KANKER 1.  Pertumbuhan cepat 2.  Menyebar 3.  Menerobos / Invasi 4.  Bebenjol tidak rata 5.  Selaput lendir berubah sifat 6.  Rapuh mudah berdarah

LABORATORIUM —  CEA: tidak akurat untuk diagnostik, baik untuk follow-up

menilai hasil pengobatan. —  Alkali fosfatase: bisa meningkat pada metastase hepar, tetapi tidak spesifik.

PRE-OPERATIVE STAGING FOR COLORECTAL CANCER —  Detect distant metastases (liver, lung, bone ) —  Detect lymph node involvement —  Local staging: Deep of penetration and surrounding organ

infiltration Ø  Chest X ray, USG, CT Scan, MRI Ø  Endosonography

TUMOR YANG TUMBUH BESAR, DINDING USUS MENEBAL DAN LOBANG USUS MENYEMPIT

STAGING RECTAL CANCER

IMPORTANT TO KNOW THE DEPTH OF TUMOR PENETRATION à EVALUATE T - ENDO ANAL ULTRASONOGRAPHY (EUS) - CT SCAN or MRI TO EVALUATE THE NODE (N): - EUS, CT, MRI TO EVAALUATE DISTANT METASTASES: - CT - CHEST X RAY

PREOPERATIVE STAGING FOR RECTAL CANCER —  Accurate information about infiltration of tumor is important for

deciding local excision, with or without preoperative chemo radiation —  The best modality for determining invasion into the layer of bowel wall is endorectal ultrasonography —  The best modality for visualization of endopelvic fascia involvements is CT or MRI, with 92% agreement with histology. —  T2 & T3 (distant to endopelvic fascia more than 2mm) need preoperative chemoradiotherapy —  Spiral CT scan: lung, liver, retroperitoneal and primary tumor can all be visualized à ‘one-stop shop’

Wiggers: Staging of rectal cancer. BJS 2003;90:895-896

TNM classification q  T= primary tumor

—  N= regional lymph nodes

Tx: primary tumour cannot be assessed T0: No evidence of primary tumour Tis: Carinoma insitu T1: Tumour invades submucosa T2: Tumour invades muscularis propria T3: Tumour invades muscularis propria into subserosa or perirectal/ pericolic tissue non peritoneal T4. Tumor directly invades other organ or perforated

Nx: Regional l.n. cannot be assessed N0: No regional l.n. metastasis N1: Metastasis in 1 to 3 reg. l.n. N2: Metastasis in 4 or more reg. l.n. —  M= Distant metastasis

Mx: Distant metastases cannot be assessed M0: No distant metastasis M1: Distant metastasis

TNM Classification Stage 0

Tis, N0, M0

Stage I

T1 or T2, N0, M0

Stage II

T3 or T4, N0, M0

Stage III

All T, N1 or N2 , M0

Stage IV

All T, All N, M1

STAGE OF DISEASE AND SURGERY OF COLON CANCER

Stage 0 Stage I Stage II Stage III Stage IV

Tis, N0, M0

Endoscopic mucosal resection (EMR)/ polipectomy T1 or T2, N0, Curative resection for T2 M0 (R0) T3 or T4, N0, Curative or paliative M0 resection (R0, R1 or R2) All T, N1 or May curative (R0) but N2 , M0 mostly paliative resection (R1 or R2) All T, All N, May be curative if M1 can M1 be completely removed

CLINICAL STAGE & MODALITY OF TREATMENT IN RECTAL CANCER —  T1-N0 :

trans anal endoscopic mucosal resection —  T2-N0: trans-abdominal resection —  T3, N0 or any T, N1-2: Preoperative chemoradiation followed by transabdominal resection —  T4 or metastatic disease: resectable à anorectal resection , unresectable à diverting colostomy, stenting & chemoradiation §  Total mesorectal excision §  Sphincter preserving procedure for middle rectal cancer.

NCCN: Practice Guidelines in Oncology-v.3.2010 Rectal cancer

Radiotherapy in colorectal cancer. Dutch Colorectal Cancer Group 1996-1999 —  924 patients preoperative radiotherapy (5Gy on each of 5 days)

followed by TME (Group I) vs 937 patients TME only (Group II) —  2 years survival: 82.0% vs 81.8% —  Local reccurrence at 2 years: 2.4% vs 8.2% (P<0.001) —  Postoperative radiotherapy was mandatory for patients with positive circumferential margin.

Keus R.B. Radiotherapy in Colorectal cancer. Dutch foundation postgraduate medical course 2004

TYPES OF SURGERY ¨  RIGHT HEMICOLECTOMY ¨  ¨  ¨  ¨  ¨  ¨  ¨  ¨  ¨  ¨ 

(EXTENDED) (A & B) TRANSVERSECTOMY (C) LEFT HEMICOLECTOMY (D) EXTENDED LEFT HEMICOLECTOMY (E) SIGMOIDECTOMY (F) SUBTOTAL/TOTAL COLECTOMY (G) ANTERIOR RESECTION SPHINCTER PRESERVING SURGERY ABDOMINO-PERINEAL RESECTION INTERNAL DIVERSION COLOSTOMY

Sphincter saving procedure: after total mesorectal excision folowed by distal irrigation, resection and anastomosis

DEFUNCTIONING ILEOSTOMY

CHEMOTHERAPY FOR COLORECTAL CANCER —  In-operable case —  Residual tumor (+) or probable after resection —  High grade malignancy